Coleman v. Roofing Concepts, Inc.Coleman v. Roofing Concepts, Inc.
OPINION
In this case plaintiff seeks benefits under a group health insurance plan, the award of which would violate important provisions of the Employee Retirement Income Security Act (ERISA),
At first glance, these appear to be three unrelated theories of recovery, but acceptance of any of them would require this court to rewrite the contract of insurance. While a court should be hesitant to depart from the written terms of a contract under any circumstances, it is particularly inappropriate in a case involving ERISA, which places great emphasis upon adherence to the written provisions in an employee benefit plan. Plaintiffs theories, though packaged in different wrappers, all would lead to the same result — the written plan would no longer be the benchmark in an action under ERISA. Accordingly, we must reverse the judgment of the district court and direct it to dismiss the complaint.
I.
Plaintiff Joanne Coleman and her husband participated in a group health insurance plan sponsored by her husband’s employer, Roofing Concepts, Inc. After terminating its group health coverage with another insurer in late 1988, Roofing Concepts was issued a group health policy by Nationwide Life Insurance Company, which took effect on November 1, 1988. The Nationwide policy fell within ERISA’s definition of an émployee welfare benefit plan, and was thereby subject to regulation under the statute.
In the contract of insurance, Roofing Concepts agreed to pay 100 percent of the premiums due on the policy. The written provisions of the plan also stated that the policy would “continue for as long as premiums are paid or until it is cancelled.” The plan allowed for a 31-day grace period after a premium due date, during which time insurance coverage would continue for the plan participants. The policy provided, however, that “[i]f all the premium is not paid prior to the expiration of the grace period, the Policy will terminate on the last day of the grace period.”
Roofing Concepts defaulted on its payments almost from the start. At the time of its application to Nationwide, Roofing Concepts paid a premium deposit of $3665.63, which equaled the estimated premium on the policy for the first month. Nationwide’s underwriters thereafter calculated the actual monthly premium to be $3709.42, $43.79 more than Roofing Concepts’ deposit. Nationwide billed Roofing Concepts for this difference, which was due on November 1, 1988. Roofing Concepts, however, never paid the $43.79, nor did it ever make another monthly premium payment. Roofing Concepts also failed to notify its employees that it had ceased paying the premiums on the policy.
Roofing Concepts went out of business on February 15, 1989. On February 16, Roofing Concepts informed Nationwide of this event and asked Nationwide to cancel the health insurance policy. On March 6, 1989, Nationwide sent a reply letter indicating that because Roofing Concepts had paid no premiums except for the initial deposit, the policy was cancelled as of its effective date, November 1, 1988.
Plaintiff Coleman was pregnant at the time of the Nationwide policy’s inception. In response to a telephone inquiry, Coleman received a letter from a Nationwide account representative dated December 1, 1988, which included her policy number as well as a brief summary of group benefits. On December 5,1988, Coleman was sent an authorization for a two-day hospital stay
Coleman claims in her affidavit that she was advised by unnamed Nationwide employees on several occasions after December 1, 1988 that she had coverage. In her deposition, however, Coleman indicated that the only time she spoke to Nationwide personnel between December 1 and the birth of her child was in January 1989 when she was told during a telephone inquiry that a tubal ligation would be covered by the policy. Coleman did contend that she spoke to Capp Care employees on numerous occasions during the same time period regarding her authorization for hospitalization.
Coleman gave birth to a son on January 25,1989. Although Nationwide paid two of the medical expenses associated with the childbirth totalling $481.60, it notified Coleman in a letter dated March 27, 1989, that the bulk of her expenses would not be paid because her coverage had been cancelled as of November 1, 1988. These uncovered expenses totalled $6976.07. When Coleman’s husband contacted Kenneth Harris, president of Roofing Concepts, to find out why the policy had been cancelled, Harris professed ignorance despite the fact that he had signed the February 16 letter to Nationwide requesting the cancellation of coverage.
Coleman filed this suit against Nationwide on January 12,1990, seeking payment of the medical expenses plus attorney’s fees. Both parties subsequently filed motions for summary judgment. On October 16, 1990, the district court denied Nationwide’s motion for summary judgment and granted Coleman’s on alternative theories of estoppel and breach, of fiduciary duty.
II.
Coleman argues that she was covered under the health insurance plan because Nationwide had no right to retroactively cancel her benefits. Although she apparently concedes that the failure of Roofing Concepts to pay the policy premiums gave Nationwide the right to cancel the policy, she contends that her coverage was in full force and effect when her child was born because Nationwide had taken no affirmative action to cancel the policy as of that time.
We believe, however, that Coleman misreads the plain language of the policy, which provides for automatic termination of the coverage if the policy’s grace period expires without payment of an overdue premium having been made. The written plan expressly states that “[i]f all the premium is not paid prior to the expiration of the grace period, the Policy will terminate on the last day of the grace period” (emphasis added). The policy also states that coverage “will continue for as long as premiums are paid or until it is cancelled.” Thus, the policy itself draws a distinction between automatic termination if Nationwide is not paid a premium and a cancellation for some other reason. On the facts of this case, Coleman’s coverage terminated no later than December 2, 1988, when the grace period for payment of the $43.79 portion of the November premium expired. The language of this plan indicating that coverage terminates automatically for failure to pay premiums is unambiguous. Courts are not at liberty to disregard the plain language of a plan in order to demand that insurers provide coverage for which
Attempts to circumvent this policy language on behalf of an admittedly appealing plaintiff would regrettably reprove the adage that hard cases make bad law. For example, adoption of Coleman’s position that the insurer has to make some affirmative acknowledgment of termination in order for such termination to have effect would not only conflict with the plain language of the plan, but might also inure to the detriment of beneficiaries in the long run. An insurer that has an automatic termination provision in its policy is not presently precluded from making the business decision to accept payment of premiums after the grace period has expired and to treat the policy as an uninterrupted one. The decision to do this, of course, does not alter the terms of the contract, but it certainly works to the benefit of plan participants whose coverage would remain in effect. Coleman’s affirmative acknowledgment rule would create an incentive for an insurer to declare a policy terminated as soon as the grace period expires in order to protect its rights. Once such a declaration is made by the insurer, tendering and acceptance of the overdue premiums to reinstate the policy seem less likely to occur. Consequently, plan participants as a whole are likely to be harmed by Coleman’s rule.
Coleman’s additional contention that the automatic termination provision constitutes an illegal “escape” clause also misses the mark. She seems to suggest that a termination clause such as this is unenforceable because it disrupts legitimate expectations of coverage or renders the insurer’s promise of coverage illusory. A contractual provision such as the one at issue here that conditions performance upon payment, however, is the essence of consideration and is in no way improper or unconscionable. See, e.g., American Family Mut. Ins. Co. v. Jones,
III.
Coleman next argues that Nationwide is estopped from denying her the requested medical benefits. She alleges that at various points between December 1, 1988, and the birth of her child, Nationwide employees and agents indicated that she was still covered by the Roofing Concepts health insurance policy. She claims that these representations estop Nationwide from asserting that her coverage had terminated pursuant to the terms of the plan and that, as a result of this estoppel, she is entitled to payment of her medical expenses notwithstanding the plan’s plain language.
Although Coleman apparently concedes that a state common law cause of action based upon equitable estoppel has been preempted by ERISA, see
Use of estoppel principles to effect a modification of a written employee benefit plan would conflict with “ERISA’s emphatic preference for written agreements.” Degan v. Ford Motor Co.,
In an effort to avoid the prohibition against using equitable estoppel to modify the written terms of a plan, Coleman claims that Nationwide’s statements constituted an interpretation, not a modification, of the written plan. Based upon this construction of the facts, she argues that we should adopt the view of the Eleventh Circuit that estoppel principles may be invoked in ERISA cases when the statements at issue are interpretations of ambiguous plan provisions. See National Cos. Health Benefit Plan v. St. Joseph’s Hosp. of Atlanta, Inc.,
We are unpersuaded by Coleman’s view that estoppel principles are available in cases involving employee welfare benefit plans, but not in pension plan cases. According to Coleman, the reason for denying use of equitable estoppel principles in pension plan cases is to protect the actuarial soundness of those plans. See Armistead v. Vernitron Corp.,
We do not think, however, that the statutory emphasis on adherence to the written terms of ERISA plans leaves room for this distinction between pension and welfare benefit plans.
We also note that several important purposes of ERISA would be impeded through use of estoppel principles in welfare benefit plan cases. ERISA is designed “to promote the interests of employees and their beneficiaries in employee benefit plans,” Shaw v. Delta Air Lines, Inc.,
In sum, we think the district court was correct to conclude that estoppel was unavailable to alter the unambiguous terms of an ERISA welfare benefit plan.
IV.
A.
In entering summary judgment in Coleman’s favor, the district court accepted her theory that Nationwide owed her benefits due to a breach of fiduciary duty. The alleged breach stems from Nationwide’s failure to notify all plan beneficiaries that Roofing Concepts had threatened their eligibility for benefits due to the failure to pay premiums. We believe, however, that in concluding that Nationwide was a fiduciary who had committed a breach, the district court failed to follow the allocation of responsibilities that the plan documents themselves provided.
Before one can conclude that a fiduciary duty has been violated, it must be established that the party charged with the breach meets the statutory definition of
[A] person is a fiduciary with respect to a plan to the extent (i) he exercises any discretionary authority or discretionary control respecting management of such plan or exercises any authority or control respecting management or disposition of its assets, (ii) he renders investment advice for a fee or other compensation, direct or indirect, with respect to any moneys or other property of such plan, or has any authority or responsibility to do so, or (iii) he has any discretionary authority or discretionary responsibility in the administration of such plan.
We believe the district court’s conclusion that Nationwide was a “fiduciary” failed to come to terms with the statutory definition. The district court seemed to regard fiduciary status as an all-or-nothing concept. However, the inclusion of the phrase “to the extent” in
The discretionary authority or responsibility which is pivotal to the statutory definition of “fiduciary” is allocated by the plan documents themselves. Cf. Firestone Tire & Rubber Co. v. Bruch,
While we find nothing in the formal allocation of responsibilities to conclude that Nationwide possessed the necessary discretionary authority to render it a fiduciary, we must also look beyond the formalities to see if Nationwide in fact exercised authority over these sorts of notifications. See Leigh,
There simply is no basis in the plan documents or Nationwide’s actions to conclude that Nationwide possessed or exercised discretionary authority or responsibility with respect to the notification at issue. We cannot blindside Nationwide by implying the existence of obligations when the only source of such obligations is judicial inventiveness. If an insurer, or any other party,
B.
Coleman also argues that Nationwide failed to fulfill the notification duties assigned in the statute to the plan administrator. ERISA allocates to the plan administrator the responsibility for providing notice of plan provisions and changes that affect the benefits of all. The plan administrator must provide a detailed summary plan description to all participants, as well as notification of any material modifications that are made to a plan.
The statute unambiguously supports the district court's determination that Roofing Concepts, not Nationwide, was the plan administrator. ERISA provides that if a plan administrator is not designated in the written plan documents, then the plan sponsor is the plan administrator.
V.
We thus reverse the judgment of the district court, including its award of attorneys’ fees, and remand the case with directions to grant summary judgment for Nationwide and dismiss the complaint. It would be improper — and legally insupportable — to require an insurer to pay on a policy where no ERISA duties were transgressed and on which the premiums were never paid. Coleman’s unfortunate situation resulted not from any fault of Nation
REVERSED.
Notes
. We also note that Nationwide breached no fiduciary duty by regarding the policy as can-celled according to its own terms. "To adhere to the plan is not a breach of fiduciary duty.” Dzinglski v. Weirton Steel Corp.,
. Coleman also argues that Nationwide breached a fiduciary duty that it owed her when it misrepresented that she had coverage even though it knew that Roofing Concepts was delinquent in the premium payments. We note, however, that the alleged misrepresentations to which Coleman seeks to hold Nationwide were mainly made by Capp Care employees. As noted above, Capp Care’s written communication to Coleman explicitly stated that its authorization for hospitalization did not guarantee payment and that it was subject to the insurer's verification of coverage. Coleman’s effort to sidestep this disclaimer cannot succeed. This theory of recovery, moreover, seems to us to be little more than a repackaging of the equitable estoppel argument made by Coleman. Even if the theory were valid, however, Coleman must still come to terms with the plain language of the plan. She brings this action under
. Nationwide’s agreement in the written plan to provide Roofing Concepts with individual certificates to be distributed to each employee eligible for coverage did not constitute an assumption by Nationwide of Roofing Concepts’ duty to provide a summary plan description. These certificates were to include an' explanation of "the main benefits and requirements" of the policy. ERISA provides a lengthy, detailed list of what must be included in a summary plan description.